NEURASTHENIA. - Of all the terms of scientific medicine, few have enjoyed the fortune and diffusion that this one has enjoyed and still enjoys, introduced by the American physician Beard (1869), as an etiopathogenetic concept, synonymous with "nervous exhaustion"; but few terms have aroused a greater number of nosographic distinctions and diversity of opinions.
In the present state of knowledge, it may be held that neurasthenia properly so called is a morbid form characterized by a peculiar emotion (different from anxiety), which is designated by the name of "alarm." The neurasthenic alarm (Bini) is a "prevailing, unpleasant feeling of diffidence and fear, with the meaning of doubt, directed at one's own capacities or, generically, at one's own health, often justified by psychaesthesia," that is, by abnormal sensations whose erroneousness originates at a psychic level.
Such a syndrome of neurasthenic alarm may appear: 1) as a psychogenic reaction, that is, as an unusual, anomalous but comprehensible manifestation, which appears following events charged with emotional value (Erlebnis), influenceable by psychic means, and which disappears without leaving traces after the removal of the causative event; 2) as connatural in a type of psychopathic personality, that is, in that stably abnormal personality which, according to K. Schneider's definition, "suffers or makes others suffer"; 3) as a psychoneurotic episode, that is, as a morbid form in which the marks of a clear psychopathic personality are lacking and in which there is no true causative event, such as occurs in psychogenic reactions. In the older descriptions of neurasthenia, the distinctions were made according to the bodily region to which the disturbances with their alarm reaction were referred, and one therefore spoke of cerebral, spinal, sexual, gastric neurasthenia, etc. Such denominations rested on the pathogenetic concept of the "exhaustion of a determined region of the nervous system." With the decline of this theory, the more recent specific nosographic descriptions abolish such distinctions, although in some authors a subdivision still persists in relation to the predominance of somatic or psychopathic symptoms: for example, K. Schneider distinguishes "somatic asthenics" from "psychic asthenics." Under the term "somatopathy" there are to be included and distinguished: 1) the vegetative reactions of the emotion (for example, the neurasthenic who polarizes himself in the tormenting doubt of a heart disease, anxiously counting the beats of his pulse, may by this emotion alone modify them objectively); 2) the neuroses (v.) and neurovegetative dystonias, without a conscious emotional genesis (for example, paroxysmal tachycardia, spastic constipation, etc.); 3) the alarm psychaesthesias, that is, a host of abnormal sensations to which no objective modification corresponds. Alongside the "psychaesthetic alarm neurasthenia," which is neurasthenia properly so called, two varieties are distinguished: the "phobic alarm neurasthenia" and the "hypochondriac neurasthenia" (in which the tenacious belief of illness stands in the foreground).
With regard to the causality of neurasthenia, many neurasthenics refer the onset of their disturbances to events of particular emotional value, for example, bereavements, financial reverses, sentimental disappointments, overwork under unsatisfactory conditions, psychic strains in general. Often such references correspond to that "need for causality," to that "post hoc ergo propter hoc" to which the judgments of patients and family members generally fall prey. Often these situations of affective discomfort are referred to and experienced with darker tints than reality: the state of suffering due to the environmental situation is more an effect than a cause of the emotional alterations, which have a fundamentally constitutional basis. A psychopathic heredity, generic or specific, is not rare. Neurasthenia may appear in all somatic constitutions, in all social classes, although it is intellectuals who suffer more intensely from the alarm, because of the possibility of a more complex elaboration of the situation. The age most affected is adulthood, with a maximum peak between 25 and 35 years (Braun, 1935) and, in women, another peak in the climacteric period. All statistics agree in affirming that during wartime periods no increase in neurasthenia is observed.
With regard to symptomatology, the neurasthenic reacts to his disturbances with a characteristic behavior. The psychaesthesias are at first interpreted as due to organic disease and the alarm as an adequate emotional expression; he therefore consults the internist, not the psychiatrist. He reports his disturbances with acuteness and wealth of detail, which are often written down on a sheet of paper ("malade au petit papier" of Charcot) to avoid forgetfulness. He demands special investigations, whose negative outcome reassures him only briefly; the improvement that follows the "restorative cure" is slight and transient. Diffidence toward the physician's judgment supervenes, "celebrities" are sought, accumulating laboratory examinations and medicines. Little by little even his family members brand him with "fixations," with "suggestions," consider him "pusillanimous," "lacking in good will." The neurasthenic reacts with liveliness and harshness to these criticisms, assuming a demanding and hostile attitude. For the most part his social and work activity is not gravely impaired, even if his judgment is exaggeratedly pessimistic. The diminution of intellectual work does not depend on a primary deficit of intellectual activity, but on the emotional disturbance.
Objective examination reveals nothing anomalous; only in the pseudoneurasthenic syndrome can small signs in the vegetative sphere be objected.
In "post-traumatic neuroses (v.)" and "compensation neuroses" (see also PSYCHONEUROSES) a neurastheniform syndrome is very frequent. These are morbid forms that arise after accidents or misfortunes, in which (Oppenheim) predominant etiopathogenetic importance was given to the physical trauma; today, on the other hand, the subsequent psychic elaboration of the trauma is placed in the foreground and the "functional" nature of the affection is emphasized. Especially in compensation psychoneuroses ("sinistros") the importance of the trauma is entirely secondary with respect to the insurance situation of the injured person. A subacute course of 4-5 months is not rare; but it is more frequent for the form to last some years, with notable variations in intensity.
Therapy with medicaments is devoid of causal usefulness; it has only a symptomatic value. Electroshock (v. SHOCK) may be attempted if an anxious or dysphoric component exists. Psychotherapy (v.) is the treatment of choice.